prevention of ischemic stroke
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Laboratory
Radiology
- diagnostic testing to determine cause of 1st stroke or TIA within 48 hours of symptom onset[28]
Management
- blood pressure control
- goals same as general population (< 140/90) or (< 150/90)[14]
- systolic BP targets of <130 mm Hg or <140 mm Hg result in similar BP reductions[19]
- amlodipine/benazepril superior to benazepril/HCTZ in reducing cardiovascular events[13]
- ACE inhibitor + thiazide diuretic decreases risk of stroke,heart failure & all-cause mortality in elderly > 80 years of age (GRS9)[9]
- preferable to ACE inhibitor + calcium channel blocker[9]
- systolic blood pressure reduction to < 140 mm HG combined with dual antiplatelet therapy started within 12 hours of stroke onset may lower early risk of ischemic stroke recurrence[29]
- goals same as general population (< 140/90) or (< 150/90)[14]
- physical activity lowers risk of recurrent ischemic stroke
- strongest negative risk factor at 3 years[20]
- consider carotid endarterectomy for 70-99% stenosis of extracranial internal carotid artery[1]
- beneficial for symptomatic carotid stenosis[1]
- risk of recurrent stroke is 26% within 2 years[1]
- carotid endarterectomy may have better outcomes than carotid angioplasty with stenting for patients > 70 yearsof age
- for younger patients, the two approaches are similar in their risks for perioperative complications & long-term ipsilateral stroke[14]
- avoid arterial stenting; procedural risk of stroke[1]
- no benefit if complete occlusion of internal carotid artery[1]
- beneficial for symptomatic carotid stenosis[1]
- see secondary prevention in patients with cardiovascular disease
- antiplatelet therapy
- aspirin 81 mg QD
- low platelet count may indicate aspirin resistance (12%)[23]
- clopidogrel (Plavix) 75 mg PO QD superior to aspirin[7]
- combination therapies
- Plavix 75 mg + aspirin 81 mg QD
- NOT superior to Plavix alone[4] (see MATCH study)
- reduces risk of recurrent stroke at the cost of increased risk for major bleeding (0.9% vs 0.2%)[22]
- most of the benefit of stroke prevention occurs in the 1st week of combination treatment
- most of the bleeding occurs later[22]
- benefit in first hours, days, & weeks after an index stroke[30]
- may reduce risk of recurrent stroke in Chinese patients[15]
- ticagrelor 180 mg on day 1, then 90 mg bid + aspirin 300-25 mg on day 1, then 75-100 mg qd reduces risk of disabling stroke at 30 days[27]
- Aggrenox (dipyridamole + aspirin)
- superior to aspirin, same benefit as Plavix[7]
- number need to treat = 67 for 1 year to prevent 1 stroke (Aggrenox vs aspirin)
- clopidogrel or aspirin + cilostazol
- initiation within 15-28 days or within 29-180 days reduces risk of recurrent stroke relative to monotherapy with aspirin or clopidogrel (RR=0.27-0.34)[30]
- initiation within 15 days of no benefit[30]
- Plavix 75 mg + aspirin 81 mg QD
- aspirin 81 mg QD
- anticoagulation for patients with atrial fibrillation
- only warfarin FDA-approved for vavular atrial fibrillation[1]
- for non-valvular atrial fibrillation, use direct oral anticoagulant[1]
- apixaban, dabigatran, rivaroxaban are reasonable options[14]
- rivaroxaban is not superior to aspirin for prevention of recurrent embolic stroke of undetermined origin & is associated with a higher risk of bleeding[21]
- statin (HMG CoA reductase inhibitor) if LDL > 100 mg/dL
- all patients with prior TIA or stroke[1]
- simvastatin useful for primary, but not secondary stroke prevention[3]
- atorvastatin may be useful for secondary stroke prevention, in high-risk patients[5][8]
- continue statin without interruption in patients with ischemic stroke who took statin prior to stroke[6]
- in very high-risk patients, goal may be LDL < 70 mg/dL[3][26]
- in hospital statin associated with improved outcomes in patients hospitalized with ischemic stroke[10]
- aggressive statin therapy (i.e. high-dose atorvastatin) recommended for secondary stroke prevention[9]
- high dose stains might be warranted for patients with ischemic stroke with evidence of atherosclerosis[31]
- ACE inhibitor + diuretic may be of some value[2]
- intensive glycemic control no better than standard care in diabetics
- folic acid 0.8 mg PO QD may reduce risk of stroke in patients with hypertension (2.7% vs 3.4%), especially in those with low serum folate[17]
- patent foramen ovale with or without atrial septal aneurysm
- no clear benefit to percutaneous closure
- aspirin & warfarin appear equivalent[1]
- patent foramen ovale closure to prevent 2nd stroke if no other cause[1]
- stroke patients should continue taking warfarin or aspirin when undergoing dental procedures or dermatologic procedures
- stroke patients should probably continue aspirin during
- invasive ocular anesthesia
- cataract surgery
- transrectal ultrasound-guided prostate biopsy
- spinal or epidural procedures
- carpal tunnel surgery[11]
- aspirin likely increases bleeding risk during orthopedic hip procedures[11]
- higher protein intake associated with lower stroke risk
- animal protein appears to confer more protection than vegetable protein
- fish may be animal protein of benefit
- AHA/ASA recommend Mediterranean diet & DASH diet[16][28]
- moderate alcohol consumption does not protect against stroke in men[24]
Additional terms
- ischemic stroke
- ischemic stroke prevention trial
- risk factors for & prevention of ischemic stroke
- secondary prevention in patients with cardiovascular disease
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 18, 19. 16, American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2018, 2022.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 2.0 2.1 Prescriber's Letter 8(7):38 2001 (subscription needed) http://www.prescribersletter.com
- ↑ 3.0 3.1 3.2 Journal Watch 24(7):55, 2004 Collins R et al, Heart Protection Study Collaborative Group Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet 363:757, 2004 PMID: https://www.ncbi.nlm.nih.gov/pubmed/15016485
- ↑ 4.0 4.1 Journal Watch 24(17):133, 2004 Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, Leys D, Matias-Guiu J, Rupprecht HJ; MATCH investigators. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo- controlled trial. Lancet. 2004 Jul 24;364(9431):331-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15276392
- ↑ 5.0 5.1 Amarenco P, Bogousslavsky J, Callahan A 3rd, Goldstein LB, Hennerici M, Rudolph AE, Sillesen H, Simunovic L, Szarek M, Welch KM, Zivin JA; Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006 Aug 10;355(6):549-59. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16899775
- ↑ 6.0 6.1 Bianco M et al, Statin treatment withdrawal in ischaemic stroke: a controlled randomized study. Neurology 2007, 69:904 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17724294
- ↑ 7.0 7.1 7.2 Prescriber's Letter 15(10): 2008 Antiplatelet Agents for Stroke Prevention Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=241010&pb=PRL (subscription needed) http://www.prescribersletter.com
Verro P, Gorelick PB, Nguyen D. Aspirin plus dipyridamole versus aspirin for prevention of vascular events after stroke or TIA: a meta-analysis. Stroke. 2008 Apr;39(4):1358-63. Epub 2008 Mar 6. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18323511
Sacco RL et al; PRoFESS Study Group. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med. 2008 Sep 18;359(12):1238-51. Epub 2008 Aug 27. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18753638 - ↑ 8.0 8.1 Callahan A et al. Risk of stroke and cardiovascular events after ischemic stroke or transient ischemic attack in patients with type 2 diabetes or metabolic syndrome: Secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. Arch Neurol 2011 Oct; 68:1245. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21670382
- ↑ 9.0 9.1 9.2 9.3 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - ↑ 10.0 10.1 Flint AC et al Inpatient statin use predicts improved ischemic stroke discharge disposition Neurology May 22, 2012 vol. 78 no. 21 1678-1683 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22614435 <Internet> http://www.neurology.org/content/78/21/1678
Flint AC et al Statin use during ischemic stroke hospitalization is strongly associated with improved poststroke survival. Stroke. 2012 Jan;43(1):147-54 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22020026 - ↑ 11.0 11.1 11.2 Armstrong MJ et al Summary of evidence-based guideline: Periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology May 28, 2013 vol. 80 no. 22 2065-2069 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23713086 <Internet> http://www.neurology.org/content/80/22/2065.full
- ↑ Wang Y et al Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. N Engl J Med. June 26, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23803136 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1215340
Hankey GJ Dual Antiplatelet Therapy in Acute Transient Ischemic Attack and Minor Stroke N Engl J Med. June 26, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23803138 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1305127 - ↑ 13.0 13.1 Jamerson K et al, Benazepril plus Amlodipine or Hydrochlorothiazide for Hypertension in High-Risk Patients N Engl J Med 2008, 359:2417-2428 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19052124
- ↑ 14.0 14.1 14.2 14.3 Kernan WN et al Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. May 1, 2014 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24788967 https://stroke.ahajournals.org/content/early/2014/04/30/STR.0000000000000024.full.pdf+html
- ↑ 15.0 15.1 Prescriber's Letter 9(9):52 2002 (subscription needed) http://www.prescribersletter.com
- ↑ 16.0 16.1 Zhang Z, Xu G, Yang F Quantitative Analysis of dietary protein intake and stroke risk. Neurology. June 11, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24920855 <Internet> http://www.neurology.org/content/early/2014/06/11/WNL.0000000000000551.abstract
Tamayo A and Castilla-Guerra L Dietary protein and stroke prevention. Is the Eskimo diet the answer to avoid stroke? Neurology. June 11, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24920851 <Internet> http://www.neurology.org/content/suppl/2014/06/11/WNL.0000000000000551.DC1/WNL.0000000000000555.pdf - ↑ 17.0 17.1 Huo Y et al Efficacy of Folic Acid Therapy in Primary Prevention of Stroke Among Adults With Hypertension in ChinaThe CSPPT Randomized Clinical Trial. JAMA. Published online March 15, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25771069 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2205876
Stampfer M, Willett W Folate Supplements for Stroke Prevention. Targeted Trial Trumps the Rest. JAMA. Published online March 15, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25770867 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=2205875 - ↑ Kernan WN et al. Pioglitazone after ischemic stroke or transient ischemic attack. N Engl J Med 2016 Feb 17 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26886418
Semenkovich CF. Insulin resistance and a long, strange trip. N Engl J Med 2016 Feb 17 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26886417 - ↑ 19.0 19.1 Mant J, McManus RJ, Roalfe A et al. Different systolic blood pressure targets for people with history of stroke or transient ischaemic attack: PAST-BP (Prevention After Stroke - Blood Pressure) randomised controlled trial. BMJ 2016 Feb 25; 352:i708 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26919870 Free PMC Article
- ↑ 20.0 20.1 Turan TN et al. Relationship between risk factor control and vascular events in the SAMMPRIS trial. Neurology 2016 Dec 21 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28003500
- ↑ 21.0 21.1 Hart RG, Sharma M, Mundl H et al Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source. N Engl J Med 2018; 378:2191-2201 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29766772 https://www.nejm.org/doi/10.1056/NEJMoa1802686
- ↑ 22.0 22.1 22.2 Johnston SC, Easton JD, Farrant M et al Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. N Engl J Med. May 16, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29766750 https://www.nejm.org/doi/full/10.1056/NEJMoa1800410
Grotta JC Antiplatelet Therapy after Ischemic Stroke or TIA. N Engl J Med. May 16, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29766754 https://www.nejm.org/doi/full/10.1056/NEJMe1806043
Tillman H, Johnston SC, Farrant M et al Risk for Major Hemorrhages in Patients Receiving Clopidogrel and Aspirin Compared With Aspirin Alone After Transient Ischemic Attack or Minor Ischemic Stroke. A Secondary Analysis of the POINT Randomized Clinical Trial JAMA Neurol. Published online April 29, 2019. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31034032 https://jamanetwork.com/journals/jamaneurology/fullarticle/2731585 - ↑ 23.0 23.1 23.2 23.3 Kim JT, Choi KH, Park MS, Lee JS, Saver JL, Cho KH Clinical significance of acute and serial platelet function testing in acute ischemic stroke. J Am Heart Assoc 2018 Jun 1; 7:e008313. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29858358 Free full text
- ↑ 24.0 24.1 Milwood IY, Walters RG, Mei XW et al Conventional and genetic evidence on alcohol and vascular disease aetiology: a prospective study of 500,000 men and women in China. Lancet. April 4, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30955975 Free Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31772-0/fulltext
- ↑ Sun L, Clarke R, Bennett D et al Causal associations of blood lipids with risk of ischemic stroke and intracerebral hemorrhage in Chinese adults. Nat Med. 2019 Apr;25(4):569-574. Epub 2019 Mar 11. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30858617
- ↑ 26.0 26.1 Amarenco P, Kim JS, Labreuche J et al. A comparison of two LDL cholesterol targets after ischemic stroke. N Engl J Med 2019 Nov 18; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31738483 https://www.nejm.org/doi/10.1056/NEJMoa1910355
- ↑ 27.0 27.1 Amarenco P, Denison H, Evans SR et al Ticagrelor Added to Aspirin in Acute Ischemic Stroke or Transient Ischemic Attack in Prevention of Disabling Stroke. A Randomized Clinical Trial. JAMA Neurol. Published online November 7, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33159526 https://jamanetwork.com/journals/jamaneurology/fullarticle/2772804
- ↑ 28.0 28.1 28.2 American Heart Association/American Stroke Association Secondary Stroke Prevention Clinical Practice Guidelines (AHA/ASA, 2021). Medscape - Jun 01, 2021. https://reference.medscape.com/viewarticle/952019
Kleindorfer DO, Towfighi A, Chaturvedi S et al 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2001. May 24 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34024117 https://www.ahajournals.org/doi/abs/10.1161/STR.0000000000000375 - ↑ 29.0 29.1 de Havenon A, Johnston SC, Easton JD et al Evaluation of Systolic Blood Pressure, Use of Aspirin and Clopidogrel, and Stroke Recurrence in the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke Trial. JAMA Netw Open. 2021;4(6):e2112551 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34086033 PMCID: PMC8178708 Free PMC article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2780598
- ↑ 30.0 30.1 30.2 30.3 Toyoda K et al. Association of timing for starting dual antiplatelet treatment with cilostazol and recurrent stroke: A CSPS.com trial post hoc analysis. Neurology 2022 Jan 24; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35074890 https://n.neurology.org/content/early/2022/01/24/WNL.0000000000200064
- ↑ 31.0 31.1 Lee M, Cheng CY, Wu YL et al Association Between Intensity of Low-Density Lipoprotein Cholesterol Reduction With Statin-Based Therapies and Secondary Stroke Prevention. A Meta-analysis of Randomized Clinical Trials. JAMA Neurol. 2022;79(4):349-358 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35188949 PMCID: PMC8861901 Free PMC article https://jamanetwork.com/journals/jamaneurology/fullarticle/2789410